Back to School, Part 2: PCOA, APPE, and Beyond

This is part 2 of a series on how pharmacy school has changed in the past couple of decades.

We have explored the first three professional years of pharmacy school, but there is much more to cover about what happens after the third year.

I am back with expert Terry Schwinghammer, PharmD, FCCP, FASHP, FAPhA, BCPS, Chair and Professor at the West Virginia University (WVU) School of Pharmacy, and we are joined by Lena Maynor, PharmD, BCPS, Clinical Associate Professor and Director of Advanced Pharmacy Practice Experiences at WVU School of Pharmacy. First, we will summarize the accreditation standards set by the Accreditation Council for Pharmacy Education (ACPE) as they apply to the fourth year of professional pharmacy school and beyond.

PCOA Exam

Before students begin the Advanced Pharmacy Practice Experience (APPE) rotations, they must take the PCOA (Pharmacy Curriculum Outcomes Assessment) exam, which is developed by the NABP. Although the exam is suitable for students in all professional years, it is often given near the end of the third year to assess whether students are ready to move on to APPEs. If areas of academic deficiency are identified based on exam performance, students can be given remedial assistance to improve their likelihood of success during the APPE rotations.

APPE Rotation Requirements

The final year of pharmacy school includes required and elective APPEs which help prepare students to be practice-ready. Many APPEs are focused on providing direct patient care. There are specific requirements for rotations in community pharmacy, hospital/health system pharmacy, ambulatory patient care, and inpatient general medicine patient care, as well as elective rotations. These APPEs serve to apply all of the knowledge and skills gained in the first three years of pharmacy school. Accreditation standards require the APPE curriculum to consist of at least 36 weeks (1440 hours). At WVU, eight 5-week rotations (40 weeks/1600 hours) are required.

Student Progression/Early Intervention

Schools must have a process to monitor student performance that will allow for early detection of academic or behavioral problems. Appropriate interventions must be developed to address these issues. The goal is to address issues early and proactively, rather than waiting until a student fails a course to take action.

Experiential Quality Assurance

Procedures must be implemented for the APPEs that facilitate achievement of course expectations, standardize key components of experiences across all sites offering the same course, and promote consistent assessment of student performance.

Program Assessment

This is emphasized to help improve the quality of education. There must be valid and reliable processes in place to access both strengths and deficiencies of the program. Programs are expected to use assessment outcome data to determine if resources are adequate and if curricular changes are required.

Postgraduate Residencies

More and more graduates are pursuing postgraduate residency training. Many schools offer various types of residencies or collaborate with local healthcare institutions to manage their residency program. Some professional pharmacy organizations contend that residency training is needed for pharmacists who wish to deliver high-level direct patient care. Graduates are encouraged to pursue residencies accredited by the American Society of Health-System Pharmacists (ASHP).

The experiential education components are required by the ACPE, but I wanted to learn more about some of the newer requirements. What if a student fails the PCOA after three years of pharmacy school? Not to worry.

According to Dr Schwinghammer, the PCOA, which is written by the NABP and has been administered since 2015, is more of a progress assessment and not a pass/fail exam. It is a standardized, 200 question-exam, with four categories of different weights—basic science (10%), pharmaceutical science (33%), social/behavior/administrative sciences (22%), and clinical sciences (35%). Students receive a raw score out of a maximum score of 700, and Dr Schwinghammer estimates that the mean score nationally is approximately 350 to 360. This exam not only shows how individual students grasp the information, but also if a school is having issues with the curriculum, indicated by students trending with poor performances on the PCOA. If a school sees that there is an area of weakness, a plan is made for improvement. In essence, the PCOA is more of a progress assessment to let students know where they are after three years of curriculum, before they enter the APPEs.

Dr. Maynor explained the APPEs in more detail. Like everything else in pharmacy school, the rotation experience has changed over the years. Students are expected to take on a more advanced role at each practice site. When the student begins a rotation, they should jump right into patient counseling and clinical services. APPE rotations generally place an increased emphasis on clinical services relative to IPPE rotations. The WVU Board of Pharmacy accepts APPE hours towards the licensing requirements, which can be helpful for students who have not met their hourly requirements through internships. However, students who have limited internship practice experience may have a steeper learning curve when they enter practice environments that are completely new to them. In states that do not require internship experience beyond IPPE and APPE, these academic rotations may be the only experience a student receives before starting out as a pharmacist.

Dr Maynor explains that each of the four required rotation types (community pharmacy, health system pharmacy, ambulatory care, and inpatient care) must each be at least 160 hours (4 weeks) long. Some rotations are a blend of rotation types, depending on what services are being offered. Dr Maynor gives the example of two different rotations at Kroger—an ambulatory care rotation and a community rotation; each based on what the students do with their day.

Elective international rotations are becoming popular with students. WVU, for example, sends students to an acute care rotation in Brazil, working on medical mission boats in the Amazon basin. There is also a rotation in South Africa, and students work in the public sector in a hospital and get a lot of exposure to specific disease states such as HIV and tuberculosis, seeing patients who have gone a long time without treatment.

Dr Maynor also explained another type of rotation called a 'longitudinal rotation.' The idea behind this is that if a student can spend an extended number of weeks at one site, rotating through different experiences, they have more time to learn because they don’t have to spend time learning each institution’s computer systems and policies. Students can be given longer projects and do research that normally cannot be done in one rotation. WVU has two such rotations in hospital practice and two in the community pharmacy setting. Applying for this type of rotation is a competitive process and geared to students who are interested in pursuing a residency. Another example is a 15-week rotation at an independent pharmacy which encompasses ambulatory care, compounding, and pharmacy ownership. A new rotation of this type is also starting in the next year and will be with a Kroger pharmacy located inside of a hospital, providing discharge counseling services.

What percent of students choose residencies? According to Dr Schwinghammer, at WVU, approximately 25-33% of students go on to apply for a residency. The matching process is done through ASHP.

Because of the increase in students applying, there are not enough residencies available across the country. Schools and national organizations are working to increase the number of available residencies. As the popularity of residencies is increasing overall, Dr Schwinghammer explains that students must differentiate themselves to stand out. The national match rate during the first round is approximately 67% (WVU has about a 70% match rate). Students who do not match in the first round can enter a phase 2, or second-round match. Counting the phase 2 match, approximately 80% of WVU students are successful in obtaining a residency position.

Remember the NAPLEX that we studied so hard for? According to nabp.pharmacy, as of Nov 2016, the NAPLEX has increased from 185 to 250 questions. Questions are divided between two areas:

• Ensure safe and effective pharmacotherapy & health outcomes (67%)
• Safe and accurate preparation, compounding, dispensing, and administration of medications and provision of health care products (33%).

Of these 250 questions, the test score is calculated from 200 questions, while the other 50 questions are used to determine appropriateness for possible inclusion in future exams. Candidates have six hours to complete the examination. Most questions are asked in a “scenario-based format,” where candidates must refer to the patient case while answering questions. There are also some stand-alone questions. The NAPLEX requires that all test questions must be answered in order; it is not possible to skip a question or go back to a question. The passing score of the NAPLEX is 75 out of a maximum of 150.

According to nabp.pharmacy, the MPJE (Multistate Pharmacy Jurisprudence Exam) combines “federal and state specific questions to test the pharmacy jurisprudence knowledge of prospective pharmacists.” The 120 questions on the exam are divided as such—Pharmacy practice (83%), licensure/registration/certification/operational requirements (15%), and general regulatory process (2%).

According to a Pharmacy Times article, NAPLEX pass rates have dropped slightly but widely vary among schools. But, I am confident that the dedicated faculty of the pharmacy schools around the country will find a way to help all students succeed in passing this exam.

Stay tuned for Back to School—Part 3, coming soon, where we speak to Eric Kinney, a current PharmD student at the WVU School of Pharmacy.